MEDICARE: MRS. KOURTNEY KOBER ELLIS D.P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	09341	LA

General Provider Information

NPI Number	:	1093264269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KOURTNEY KOBER ELLIS D.P.T.

Provider Business Mailing Address
First Line	:	4080 NELSON RD
Second Line	:	SUITE 500
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2439
Country	:	US
Telephone Number	:	337-494-7546
Fax Number	:	337-494-7548

Provider Business Practice Location Address
First Line	:	4080 NELSON RD
Second Line	:	SUITE 500
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2439
Country	:	US
Telephone Number	:	337-494-7546
Fax Number	:	337-494-7548

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2016
Last Update Date	:	09/28/2016

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